GUIDE ZBI+CG Information

1
Are you a caregiver for someone else living with dementia?* This field is required.
YESNO
2
This assessment is only for caregivers of others living with dementia.
End assessment
3
1) Do you feel stressed between caring for your relative and trying to meet other responsibilities for your family or work?* This field is required.
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
4
2) Do you feel embarrassed because of your relative's behavior?* This field is required.
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
5
3) Do you feel angry when you are around your relative?* This field is required.
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
6
4) Do you feel that your relative currently affects your relationship with other family members or friends in a negative way?* This field is required.
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
7
5) Are you afraid what the future holds for your relative?* This field is required.
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
8
6) Do you feel strained when you are around your relative?* This field is required.
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
9
7) Do you feel that you do not have as much privacy as you would like because of your relative?* This field is required.
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
10
8) Do you feel that your social life has suffered because you are caring for your relative?* This field is required.
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
11
9) Do you feel uncomfortable about having friends over because of your relative* This field is required.
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
12
10) Do you feel that you have lost control of your life since your relative’s illness?* This field is required.
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
13
11) Do you wish you could just leave the care of your relative to someone else?* This field is required.
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
14
12) Do you feel uncertain about what to do about your relative?* This field is required.
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
15
13) Do you feel that you should be doing more for your relative?* This field is required.
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
16
14) Do you feel you could do a better job in caring for your relative?* This field is required.
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
17
15) Overall, how burdened do you feel in caring for your relative?* This field is required.
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
18
16) Do you feel that your relative asks for more help than (s)he needs?* This field is required.
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
19
17) Do you feel that because of the time you spend with your relative that you do not have enough time for yourself?* This field is required.
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
20
18) Do you feel your relative is dependent upon you?* This field is required.
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
21
19) Do you feel your health has suffered because of your involvement with your relative?* This field is required.
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
22
20) Do you feel that your relative seems to expect you to take care of him/her as if you were the only one he/she could depend on?* This field is required.
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
23
21) Do you feel that you will be unable to take care of your relative much longer?* This field is required.
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
24
22) Do you feel that you do not have enough money to care for your relative in addition to the rest of your expenses?* This field is required.
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
25
What Is Your Name (Caregiver/POA)* This field is required.
First Name
Last Name
26
What Is Your Gender (Caregiver/POA)* This field is required.
Male
Female
Unknown
27
What Is Your Relationship to Patient (Caregiver/POA)* This field is required.
Please Select
Please Select
Spouse
Domestic Partner
Daughter
Son
Sibling
Other Family Member
Friend
Other Non-Family Member
28
What Is Your Date of Birth (Caregiver/POA)* This field is required.
MM/DD/YYYY
29
Where Does The Person With Memory Loss Live?* This field is required.
In a private home/apartment
In an assisted living facility
In a memory care facility
30
Do you currently live with the person with memory loss? (Caregiver/POA)* This field is required.
Yes
No
31
How long have you been in the role of primary caregiver?* This field is required.
0-3 Months
6-9 Months
9-12 Months
12+ Months
32
What Is Your Address (Caregiver/POA)* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
33
What is your Medicare Benefit Identification (MBI) number (If Applicable)? (Caregiver/POA)
Leave blank if you do not have Medicare
34
Submit to get the care you deserve

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